EVOLUTION MEMBERS FORUM
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Evolution Partners Membership Application
Step 1 of 3
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General Information
YOUR NAME
I AM A PRINCIPAL/OWNER OF THE AGENCY
YES
NO
AGENCY NAME (as it appears on licenses)
DBA (if applicable)
WEBSITE ADDRESS
LEGAL ENTITY
SOLE PROPRIETOR
PARTNERSHIP
CORPORATION
LIMITED LIABILITY COMPANY OTHER
OTHER
MAILING ADDRESS
CITY
STATE
ZIP
PHYSICAL ADDRESS (if different than mailing)
CITY
STATE
ZIP
CONTACT EMAIL ADDRESS
PHONE
FAX
FEDERAL TAX ID NUMBER
NUMBER OF YEARS IN BUSINESS
AGENCY LICENSE NUMBER
E&O CARRIER
E&O POLICY NUMBER
E&O LIABILITY LIMITS
E&O EXPIRATION DATE
Carrier & Production Information
TOTAL AGENCY ANNUAL PREMIUM VOLUME
NUMBER OF PRODUCERS
NUMBER OF CSR’S
TOTAL PERSONAL LINES ANNUAL PREMIUM VOLUME
TOTAL COMMERCIAL LINES ANNUAL PREMIUM VOLUME
Carriers Represented (attach additional pages if necessary)
CARRIER 1
NAME OF CARRIER
DIRECT APPOINTMENT
WHOLESALER/MGA
ESTIMATED ANNUAL PREMIUM VOLUME
ESTIMATED QUOTES PER MONTH
TYPE OF CARRIER
PERSONAL
COMMERCIAL
BOTH
WOULD YOU LIKE TO MOVE TO EVOLUTION?
YES
NO
CARRIER 2
NAME OF CARRIER
DIRECT APPOINTMENT
WHOLESALER/MGA
ESTIMATED ANNUAL PREMIUM VOLUME
ESTIMATED QUOTES PER MONTH
TYPE OF CARRIER
PERSONAL
COMMERCIAL
BOTH
WOULD YOU LIKE TO MOVE TO EVOLUTION?
YES
NO
CARRIER 3
NAME OF CARRIER
DIRECT APPOINTMENT
WHOLESALER/MGA
ESTIMATED ANNUAL PREMIUM VOLUME
ESTIMATED QUOTES PER MONTH
TYPE OF CARRIER
PERSONAL
COMMERCIAL
BOTH
WOULD YOU LIKE TO MOVE TO EVOLUTION?
YES
NO
CARRIER 4
NAME OF CARRIER
DIRECT APPOINTMENT
WHOLESALER/MGA
ESTIMATED ANNUAL PREMIUM VOLUME
ESTIMATED QUOTES PER MONTH
TYPE OF CARRIER
PERSONAL
COMMERCIAL
BOTH
WOULD YOU LIKE TO MOVE TO EVOLUTION?
YES
NO
Carriers Needed (attach additional pages if necessary)
CARRIER 1
NAME OF CARRIER
ESTIMATED ANNUAL PREMIUM VOLUME COMMITMENT
ESTIMATED QUOTES PER MONTH
TYPE OF CARRIER
COMMERCIAL
PERSONAL
BOTH
WHAT TARGET INDUSTRIES OR AREAS OF SPECIALlZATION DO YOU NEED THIS CARRIER FOR?
CARRIER 2
NAME OF CARRIER
ESTIMATED ANNUAL PREMIUM VOLUME COMMITMENT
ESTIMATED QUOTES PER MONTH
TYPE OF CARRIER
COMMERCIAL
PERSONAL
BOTH
WHAT TARGET INDUSTRIES OR AREAS OF SPECIALlZATION DO YOU NEED THIS CARRIER FOR?
CARRIER 3
NAME OF CARRIER
ESTIMATED ANNUAL PREMIUM VOLUME COMMITMENT
ESTIMATED QUOTES PER MONTH
TYPE OF CARRIER
COMMERCIAL
PERSONAL
BOTH
WHAT TARGET INDUSTRIES OR AREAS OF SPECIALlZATION DO YOU NEED THIS CARRIER FOR?
Agency Technology
AGENCY MANAGEMENT SYSTEM
COMPARATIVE RATING SYSTEM(S)
OTHER SALES AND MARKETING SYSTEMS USED (CRM, LEAD GENERATION, MARKETING AUTOMATION)
PREMIUM FINANCE COMPANIES USED
Agency Business Plan
AREAS OF SPECIALIZATION IN YOUR AGENCY
ANY AREAS THAT YOU WOULD LIKE TO TARGET OR SPECIALIZE IN (WITH THE RIGHT CARRIERS)?
HOW CAN WE BEST ASSIST YOUR AGENCY TO PROMOTE TARGET MARKETING (LEADS, NICHE PROGRAMS, ETC.)
HOW CAN MEMBERSHIP IN EVOLUTION HELP YOUR AGENCY GROW?
Agency Business Plan (continued)
HOW DOES YOUR AGENCY GENERATE NEW BUSINESS?
HOW MUCH DO YOU PLAN TO GROW YOUR AGENCY THIS YEAR? (%)
DO YOU ADVERTISE? IF SO, WHAT TYPE OF ADVERTISING DOES YOUR AGENCY DO?
DOES YOUR AGENCY TELEMARKET OR INVEST IN LEAD GENERATION?
DO YOU BELONG TO ANY ASSOCIATIONS?
DO YOU CURRENTLY HAVE ANY PROGRAM BUSINESS OR HAVE PLANS TO PURSUE IN THE NEAR FUTURE?
DO YOU PLAN ON HIRING PRODUCERS OR ADDING TO YOUR SALES FORCE?
ADDITIONAL INITIATIVES AND GROWTH PLANS:
PREMIUM GOALS
1ST YEAR
PROJECTED QUOTES PER MONTH
AVERAGE WRITTEN PREMIUM PER POLICY
PROJECTED NUMBER OF POLICIES ISSUED MONTHLY
2ND YEAR
PROJECTED QUOTES PER MONTH
AVERAGE WRITTEN PREMIUM PER POLICY
PROJECTED NUMBER OF POLICIES ISSUED MONTHLY
3RD YEAR
PROJECTED QUOTES PER MONTH
AVERAGE WRITTEN PREMIUM PER POLICY
PROJECTED NUMBER OF POLICIES ISSUED MONTHLY
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